Sanitation overview in Indonesia: How close are we to lowering the stunting number to 14%?

At the beginning of the year, we were warned about the reality of sanitation and environmental health in Indonesia. Based on the study of household water quality (Ministry of Health, 2022), it is found that nearly 70% of household drinking water sources are contaminated by E. coli. This finding can be an indicator of poor sanitation. But what exactly is sanitation, and how big is the scope of the problem? What impacts are related to sanitation?

What is sanitation?

Sanitation, according to the WHO, is defined as the provision of facilities and services for the safe disposal of human urine and faeces [1]. In a broader definition, sanitation is a strategy to promote health by preventing human contact with wastes that pose a threat of microbiological, biological, or chemical agents of disease. Human and animal faeces, solid waste, domestic wastewater (sewage, sullage, and greywater), industrial wastes and agricultural wastes pose potential health hazards [2].

Figure 2. Classification of domestic wastewater which play a big role in sanitation

The principles for implementation of sanitation interventions designed by WHO include [3]:

1. Safe sanitation system: The sanitation system should address the following minimum requirements to ensure safety along each step of the sanitation service chain.
2. Implementation of toilets with consideration of design (excreta separation design), choice of durable material, the durability to prevent intrusion of rainwater, stormwater runoff, animal and insects. It also needs to include the provision of culturally and context-appropriate for anal cleansing, handwashing, and menstrual hygiene management.
3. Implementation of containment – storage/treatment: sufficient vertical and horizontal distance between the base of the permeable container, soak pit or leach field and the local water table and/or drinking water source.
4. Conveyance: emptying mechanism, the quality of safety for all workers in the field (including SOPs and protective equipment).
5. Treatment: both the liquid and solid fractions require treatment before end use/disposal, and the treatment facility should be designed and operated according to the specific end use/disposal objective and operated using a risk assessment and management approach.
6. End-use/disposal: faecal sludge and effluent should be handled by trained workers, equipped with SOPs, protective equipment and the system is equipped with a multi-barrier approach (the use of more than one control measure as a barrier against any pathogen hazard)
7. Sanitation behaviour change:
   • adequate regulation and funding provided by the government and critical stakeholders,
   • include a robust sanitation promotion/behaviour change programme including monitoring and evaluation),
   • understanding the existing sanitation behaviours and the determinants of those behaviours, designing a behaviour change targeting the determinants of behaviour is proven to be most successful,
   • careful consideration should be given to the intervention delivery model (stand-alone behaviour change versus integrated approaches; focused versus comprehensive strategies), and supported by adequate and dedicated resources.

 Based on a study conducted by WHO in 2020, safe sanitation can reduce the disease index by 0.39 percent, children who live without safe sanitation are more prone to stunting by 0.87 times and an average investment of USD 1 will provide a benefit of USD 5, 5 and for the drinking water sector, it provides a benefit of USD 2.

Impact of poor sanitation [4][5][6]

Poor sanitation limits people's access to water and a hygienic lifestyle, it limits antiseptic usage, and washing habits, and limits the separation of excreta into domestic places. This increases the risk of transmission of diarrhoeal diseases like cholera, dysentery, typhoid, intestinal worm infections, and polio. In poor livelihood, this is experienced by young children, lowering their quality of life. 

Due to the increasing potential of illness antimicrobial-drug resistance may occur. As infectious diseases spread because of poor water, sanitation, and hygiene, antibiotic drugs usage will also increase. This can potentially lead to higher chance of antimicrobial-drugs resistance in the long run. It is critical to reduce antibiotic use to prevent the emergence and spread of antibiotic-resistant bacteria. 

Limited water access is one of the most prominent causes of inadequate nutritional intake which can increases the risk of stunting in young children. Stunting can also have long-term consequences, such as impaired cognitive and physical development, lower test scores, lower household expenditure per capita, a higher risk of poverty, an increased risk of obstructed labour and asphyxia during childbirth, and an increased risk of degenerative diseases like obesity, diabetes, heart disease, stroke, hypertension, and cancer.

Poor sanitation can severely affect the surrounding environment too. Wastewater that is emptied or leaked into the water body can pollute the water, affecting plant and aquatic life. Without proper sanitation, water reusability may not be optimal. When managed correctly, yellow water is rich in N-nutrients and can be harvested for other uses. Greywater that is not mixed with other water stream and properly treated can be returned to almost any point in the water cycle to be recycled for another purpose.

Sanitation in Global Agenda

Sanitation is addressed in the 2030 Agenda for Sustainable Development, which calls for 'ensuring the availability and sustainable management of water and sanitation for all' under SDG6. Many developments have been successful, but five years into the SDGs, the world is not on track to achieve SDG targets 6.1 and 6.2.

Achieving universal coverage by 2030 will require a quadrupling of current rates of progress in safely managed drinking water, safely managed sanitation, and basic hygiene services [7].

Sanitation in Indonesia

The plan for sanitation in Indonesia is mandated in RPJMN 2020 – 2024 as listed below:

1. 100 percent access to safe drinking water, including 15 percent access to safe drinking water, and 30 percent access to piped drinking water.
2. 90 percent access to proper sanitation, including 15 percent access to safe sanitation, and zero percent open defecation (BABS).

The 2020 National Socio-Economic Survey (Susenas) noted the recent progress made:

1. Indonesia has achieved 90.2% access to safe drinking water, including 20.7% access to pipes.
2. Achieved 79.5% for access to proper sanitation, including 7.6% for safe sanitation,
3. Achieved the decrease of open defecation to 6.2%

While the 2020 Household Drinking Water Quality Study notes the achievement of access to safe drinking water reaches 11.9 percent [8].

Despite of the progress Indonesia has made so far, inequality of access to sanitation persist. Factors that significantly affect the inequality are particularly geographic locations and service quality, which relied on the human resource and financial strength of an area.

According to The Finance Ministers' Meeting in 2020 [9], there is a huge potential in the sanitation market up to IDR 116.7T (USD 8.33 Billion) for onsite sanitation only to achieve 2024 National Medium-Term Development Plan (RPJMN 2024). The WASH (Water, Sanitation, and Hygiene) sector in Indonesia also creates significant amount of job opportunities, this includes the WASH community-based program that has absorbed nearly 27.000 human resources and 57.225 workers in 380 water utilities across Indonesia. These opportunities can be utilized and increased by increasing greater investment from various funding sources. The majority of investment for sanitation now are sourced from governments (63% in water supply and 53% in sanitation). But now, alternatives funding is sourced from zakat (moslem's charity fund), micro-credits, and small and ultra-micro business. Partnership with private sector is also being strengthened, supported by the development of financing instruments such as Indonesia's Green Bod/Green Sukuk, SDG Indonesia One [10], Multilateral Development Banks, and Green Climate Fund.

Specific case of sanitation near water bodies

Coastal habitats, fisheries, marine wildlife, and people living near several large coastal areas, including the South Asian Sea, are all threatened by untreated sewage discharge into coastal waters because of polluted watersheds, leaving some of the water unusable [11].

Based on several journals and literature, the geographical conditions of the islands cause differences in access to developments including water and water infrastructure of an island. Riverside and coastal areas in Indonesia are also commonly found in poor sanitation conditions [12] [13] [14] [15]. Conditions in areas that are close to water, such as islands or settlements near rivers, have specific characteristics. such as high water-levels that lead to high chances of seepage or cause the septic tank to float easily [16]. 

Global warming and climate change also have a direct impact on sanitation conditions in settlements near water bodies. With the increasing water level in the area, the choice of sanitation infrastructure such as septic tanks, types of toilets, is increasingly limited and more vulnerable to disasters such as floods and inundation caused by them [17].

Some locally developed alternatives in Indonesia for sanitation in areas near water bodies include the Tripikon-S septic tank and Tripikon-H septic tank [18] [19], while other units like septic tank, anaerobic baffled reactor (ABR), Anaerobic Upflow Filter (AUF), Rotating Biological Contactor, and biofiltration tank are applicated but limited to the space available in the area. Tripikon-S or Tripikon-H is used for housing located in water areas, such as rivers or swamps. This is motivated by the unavailability of land to make conventional septic tanks, due to housing conditions that are above the waters. 

Figure 2. Tripikon-S, a locally developed alternatives for toilet for wet areas

Stunting in Indonesia

Stunting is a condition of failure to grow due to chronic nutritional deficiencies and psychosocial stimulation and exposure to repeated infections, especially in the first 1,000 days of life from the fetus to children aged two years. The child is classified as stunted if the length or height is below the minus two standard deviations (-2sd) of their age [20].

Based on data from the Indonesian Toddler Nutrition Status Survey (SGBI) 2021, the prevalence of stunting in Indonesia is still at 24.4 percent, or around 5.53 million children under five. While the target of decreasing the prevalence of stunting in Indonesia is as low as 14% in 2024.

Based on the distribution of geography, there are still 19 regions in Central Java that are in the yellow category with or prevalence of 20 to 30 percent. Then 15 other districts/cities are categorized as green with prevalence in the range of 10 to 20 percent.

Based on the Central Statistics Agency, 10 provinces with the number of villages sufferers of lack of nutrition (2021) include [21]:

1. East Nusa Tenggara (1,671 villages), 
2. East Java (1,418 villages), 
3. Central Java (1,361 villages), 
4. North Sumatra (856 villages), 
5. West Java (816 villages), 
6. Aceh (734 villages), 
7. Central Sulawesi (480 villages), 
8. South Sulawesi (387 villages), 
9. South Sumatra (273 villages)
10. West Nusa Tenggara (269 villages).

Various results of desk reviews and formative research conducted by the Ministry of Health show that various behaviours in the community are found not optimal to lower stunting numbers. Pregnant women need a nutritional diet, but it is found that her environment including her mother or her husband functions more to decide the nutritional intake she eats. Early breastfeeding (one hour of birth) is also yet to become a norm. In Indonesia, it is found that babies at the age of four and five months are introduced to additional food (semi-solid or solid food) too early. Generally, economic status and food taboo are still very influential factors in Indonesia. Sanitation also played a big role, the study found handwashing behaviour with soap before eating, cooking, or when feeding is still low. Inequality of access to drinking water and sanitation is still quite large too, especially in Eastern Indonesia. Access to limited health service facilities also affects community compliance, especially among pregnant women and nursing mothers,

Youth participation in sanitation

The role of youth is very important for the development of sanitation conditions. Youth can take part in many sectors, including education and community engagement, policy advocators, program implementers and collaborators, entrepreneurship, and the opportunity to become sanitation experts who can develop solutions to sanitation problems [22] [23] [24]. Young people who are open to the issue of climate change, and social issues, and knowledgeable in the local context will be the drivers of changes in sanitation conditions in their area. Because sanitation is a complex issue, young people are able to not always see solutions through a hard-infrastructure approach, but through a multi-sectoral approach. Water resources and public health alone is the common property of different generations.

 References:

[1] World Health Organization and UNICEF, "Progress on Household Drinking Water, Sanitation, and Hygiene 2000-2020: Five years into the SDGs," 2021.
[2] M. Dobe, A. K. Sur and B. B. Biswas, "Sanitation: the hygienic means of promoting health," Indian J. Public Health, vol. 1, pp. 49-51, 2011.
[3] World Health Organization, "Guidelines on Sanitation and Health," WHO, Geneva, 2018.
[4] B. b. Baykal, "Recycling/reusing grey water and yellow water (human urine): motivations, perspectives and reflections into the future," Desalination and Water Treatment, vol. 172, pp. 212-223, 2019.
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[6] "The Association Between Sanitation, Hygiene, and Stunting in Children Under Two-Years (An Analysis of Indonesia's Basic Health Research, 2013)," Makara J. Health Res., vol. 21, no. 2, pp. 35-41, 2017.
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[9] SWA, "Sanitation and Water for All: Financ Minisiters' Meeting," December 2020. [Online]. Available: https://www.sanitationandwaterforall.org/sites/default/files/2020-12/2020_Country%20Overview_Indonesia.pdf. [Accessed March 2022].
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[24] ADB Knowledge Events, "Youth Engagement Models for Water Supply and Sanitation Projects: Lessons from Dushanbe," June 2019. [Online]. Available: https://events.development.asia/system/files/materials/2019/06/201906-youth-engagement-model-water-supply-and-sanitation-projects-lessons-dushanbe.pdf. [Accessed March 2022].

Written by: Amanda Abiella Resmana (The Water Agency)